NCLEX-RN
Saunders NCLEX RN Practice Questions
1. A nurse is caring for an in-patient client in the hospital who is from another country and who fasts for temporary periods in order to promote his own spiritual growth. The nurse responds by saying, 'You need to eat something while you are here. Food and proper nutrition are extremely important for your health.' What social philosophy is the nurse demonstrating?
- A. Ethnocentrism
- B. Relativism
- C. Stereotyping
- D. Xenocentrism
Correct answer: A
Rationale: The nurse's response reflects ethnocentrism, a belief that one's own cultural practices are superior to others. Ethnocentrism involves viewing one's own culture as the standard by which all others should be judged. In this scenario, the nurse's insistence that the client needs to eat disregards the client's cultural and spiritual beliefs, considering only the nurse's perspective as valid. B: Relativism is the recognition and acceptance of cultural differences without judgment. The nurse's behavior does not align with relativism as there is a lack of understanding and acceptance of the client's cultural practices. C: Stereotyping involves making assumptions about individuals based on predefined characteristics. While the nurse may have made assumptions, the core issue in this scenario is the belief in the superiority of one's own cultural practices. D: Xenocentrism is the opposite of ethnocentrism, where one perceives other cultures as superior to their own. The nurse's actions are not driven by a belief in the superiority of the client's culture but rather by a belief in the superiority of her own cultural practices.
2. When a blood pressure cuff is too wide for a client's arm, what type of reading might this blood pressure cuff produce?
- A. A normal reading
- B. An abnormally low reading
- C. An abnormally high reading
- D. A fluctuating reading
Correct answer: B
Rationale: When a blood pressure cuff is too wide for a client's arm, it may produce an abnormally low blood pressure reading. This occurs because the oversized cuff can lead to an underestimation of blood pressure. It is essential to ensure that the cuff fits appropriately to obtain an accurate reading. An abnormally high reading (Choice C) is less likely with an oversized cuff, as it generally leads to lower readings. A normal reading (Choice A) is unlikely due to the inaccuracies caused by the oversized cuff. A fluctuating reading (Choice D) is not a typical result of using a cuff that is too wide; instead, it usually leads to consistently low readings.
3. Richard is a 72-year-old with stage 4 lung cancer who has been admitted to the hospital for pneumonia. He is alert and oriented and states he would like to sign a do not resuscitate (DNR) order. His wife enters the room after he has signed it and is very upset that he has made this decision without discussing it with her. She wants to know what she can do to get the DNR reversed. What should your first response be?
- A. Contact the unit manager to talk with her
- B. Contact the hospital's attorney to discuss with her
- C. Try to talk Richard out of his decision
- D. Offer caring support for both parties
Correct answer: D
Rationale: The correct response in this situation is to offer caring support for both parties. Richard, being alert and oriented, has the right to make his own decisions, including signing a do not resuscitate (DNR) order. It is important to respect his autonomy while also acknowledging his wife's feelings. By offering caring support, the nurse can facilitate a discussion between Richard and his wife, helping them navigate their emotions and decisions. Contacting the unit manager or hospital's attorney would not be appropriate as the initial response. These actions may escalate the situation and are not focused on addressing the emotional needs of the couple. Trying to talk Richard out of his decision would disregard his autonomy and right to make choices about his own care, which goes against ethical principles of patient autonomy and informed decision-making.
4. You are creating a teaching plan for a patient with newly diagnosed migraine headaches. Which key item should NOT be included in the teaching plan?
- A. Avoid foods that contain tyramine, such as alcohol and aged cheese.
- B. Avoid drugs such as Tagamet, nitroglycerin, and Nifedipine.
- C. Continue taking estrogen as prescribed by your physician.
- D. A potential side effect of medications is rebound headache.
Correct answer: C
Rationale: The correct answer is C: Continue taking estrogen as prescribed by your physician. Medications such as estrogen supplements may actually trigger a migraine headache attack. Fluctuations in estrogen, such as before or during menstrual periods, pregnancy, and menopause, seem to trigger headaches in many women. Choices A and B are important to include in the teaching plan for a patient with migraines as avoiding foods containing tyramine and certain drugs can help prevent migraine triggers. Choice D is also relevant as it is essential for the patient to be aware of potential side effects of medications, including rebound headaches.
5. Select the age group that is coupled with an infectious disease that is most common in this age group.
- A. Infants: High bilirubin
- B. Pre-School and School Age Children: Shingles
- C. Young Adults and Teenagers: Sexually transmitted diseases
- D. The Elderly: Malaria
Correct answer: C
Rationale: Young adults and teenagers are at the highest risk for sexually transmitted diseases due to their sexual activity. High bilirubin is a laboratory finding related to jaundice and not an infectious disease. Shingles is more common in the elderly population, not in pre-school and school-age children. Malaria is not most common in the elderly; it is prevalent in regions with specific mosquito vectors. Therefore, the correct answer is that young adults and teenagers are most commonly associated with sexually transmitted diseases.
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